Echocardiographic Imaging in Transcatheter Structural Intervention

Figures

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  Figure 1. Echocardiography-Fluoroscopy Fusion Imaging (A) Biplane transesophageal echocardiography (TEE) showing the mitral valve (MV) in the left ventricular outflow (purple) and bicommissural (green) planes. After co-registration, the TEE data set is aligned in the echocardiographic-fluoroscopy fused images. (B) The purple and green sectors of the corresponding 2-dimensional TEE views. (C) The MV within the boundaries of the 3-dimensional pyramidal data set is aligned in the anterior-posterior fluoroscopic projection. The red arrow denotes the wire in the ventricle. (D) Another example shows the ideal transseptal puncture site being determined by biplane TEE in the bicaval and short-axis views. (E) Placement of fiducial marker (red circle) will be displayed on fluoroscopy. (F) In addition, superimposing the color Doppler TEE data set of the MV during a transcatheter edge-to-edge repair to indicate origin of the regurgitation jet can be performed. LA = left atrium; RA = right atrium; SVC = superior vena cava.

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  Central Illustration. Developing Interventional Echocardiography in Asia Development in interventional echocardiography requires having a structured curriculum to ensure competency in the field, access to novel echocardiographic modalities, and close networking within the region.

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  Figure 2. Imaging of the Interatrial Septum (IAS) (A) Three-dimensional TEE shows the IAS seen from the right atrium. The red dashed line corresponds to the bicaval view and the blue dashed line to the short-axis view. (B) Biplane TEE demonstrated tenting of the IAS (white arrows) seen from bicaval view (left) and short-axis (right) planes. Ant = anterior; AoV = aortic valve; IVC = inferior vena cava; Post = posterior; other abbreviations as in Figure 1.

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  Figure 3. Normal Structure of IAS Three-dimensional (3D) TEE showing (A to C) right and (D) left septal perspectives of the IAS: (A) 3D spatial relation of the IAS to adjacent structures can be assessed in great detail; (B) transillumination imaging with virtual light source placed in the LA behind the IAS allows appreciation of the thinness, location, and limbus of the fossa ovalis (FO); (C) photorealistic transparency (“glass”) rendering of the IAS; and (D) transillumination of the FO from the left septal perspective with virtual light source in the RA. AV = atrioventricular; CS = coronary sinus; TV = tricuspid valve; other abbreviations as in Figures 1 and 2.

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  Figure 4. Interrogation of the ASD Rims (A) ASD en face from 3D TEE view, looking in from the RA. Colored lines represent the degree of views correlated with the respective TEE 2-dimensional views. (B) corresponds to the blue line in A and shows the posterior rim and the aortic rim (midesophagus, at 0°-45°). (C) corresponds to the green line in A and shows the IVC and aortic rim (midesophagus, at 45°-90°). (D) corresponds to the red line in A and shows the IVC and SVC rim (midesophagus, at 100°-130°). (E) corresponds to the purple line in A and shows the AV valve and the posterior rim (midesophagus, at 150°-180°). Abbreviations as in Figures 1, 2, and 3.

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  Figure 5. Transseptal Puncture Height A lower puncture is needed when treating lateral lesions, because often the clip will continue to gain height above the valve as it is passes further. Conversely, a higher puncture is used when treating a medial lesion, because the clip will have to “dive down” immediately after transseptal puncture. P1, P2, and P3 = scallops of the posterior mitral leaflets.

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  Figure 6. Views for Clip Steering and Perpendicularity (A) The bicommissural “index” view allows assessment of medial and lateral device location, as well as precise localization of the area of interest. When the shaft of the delivery system approaches from too much of an anterior position (ie, an “aorta-hugger” position), as seen in (B) the long-axis “grasping” and (C) 3-dimensional en-face views, remedial maneuvers are frequently required (yellow dashed arrow).

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  Figure 7. Views for Clip Grasping and Closure (A) Biplane imaging of the clip as it is pulled back toward the mitral valve with arms fully extended and the leaflets have been grasped by the grippers. (B) The clip is then closed, and the leaflets are drawn into the mechanism. (C) Color-flow Doppler is used to assess for residual regurgitation. (D) Three-dimensional en-face imaging is used to assess the tissue bridge, the nature of the dual-orifice anatomy, and the position and volume of regurgitant jets.

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  Figure 8. Transcatheter Mitral Valve-in-Valve (A) Transseptal puncture performed with X-plane imaging. (B) X-Plane imaging using simultaneous midesophageal bicommissural and long-axis views used to guide prosthesis delivery and deployment, and to check leaflet mobility after deployment. (C) Three-dimensional reconstruction with color Doppler is used to assess for paravalvular leaks.

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  Figure 9. Echocardiographic Guidance of Percutaneous Transluminal Mitral Commissurotomy (PTMC) 3D TEE guides the alignment and orientation of the balloon catheter and further monitors the position of the inflated balloon. These pictures show the inflated Inoue balloon via (A) real-time 3D and (B) en-face views. (C, D) Left ventricular perspective 3D imaging showing splitting of both commissures (arrows) after successful PTMC, with increase in valve area and reduction of transvalvular pressure gradient on Doppler assessment (E, F). Abbreviations as in Figures 1 and 3.

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  Figure 10. Transcatheter Edge-to-Edge Repair of the Tricuspid Valve (A) Guide catheter and catheter delivery system (CDS) introduction. (B) Steering of the CDS (arrows) toward the tricuspid anteroseptal commissure using an en face view. (C) Multiplane imaging showing positioning of the CDS. (D) Multiplanar reconstruction with the long axes (red and green) aligned to the CDS. (E, F) Clip arm orientation adjusted perpendicular to the line of coaptation between the anterior and septal leaflet. (G, H, I) Leaflet grasping is monitored, and leaflet insertion confirmed with the use of multiple views. 4Ch = four-chamber; AL = anterior leaflet; LAX = long axis; LE = low-esophageal; MPR = multiplanar reconstruction; PL = posterior leaflet; SAX = short axis; SL = septal leaflet; TG = transgastric; TTE = transthoracic echocardiography; other abbreviations as in Figures 1, 2, and 3.

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  Figure 11. Tricuspid Valve Transcatheter Annuloplasty Procedure (A, B) Preprocedural TTE demonstrating tricuspid regurgitation (TR) on computed tomographic imaging. (C) X-Plane imaging using right ventricular inflow-outflow showing torrential regurgitation. (D) Through the guiding catheter, the K-Clip delivery catheter (KCR) is introduced into the RA and steered toward the tricuspid annulus (TA). (E) Fluoroscopy showing the anchor of the device to the posterior TA. (F) Retraction of the anchor, pulling annular tissue into the device, which then closes to fold the annulus within. (G) Annular and TR reduction immediately after implantation. (H) Coronary angiogram confirming right coronary patency after clipping. (I) Sustained TR reduction at 3-month follow-up. An = anchor; At = annular tissue; GC = guiding catheter; RCA = right coronary artery; other abbreviations as in Figures 1 and 10.